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* 1. Personal Information:

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* 2. Are you living with a chronic health condition? If yes, specify in the space provided.

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* 3. Do you care for someone living with a chronic health condition? Such as a spouse, family member etc

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* 4. Have you ever taken the Chronic Disease Self-Management Workshop as a participant?
If yes, please specify date and location:

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* 5. Languages other than English that you are able to lead workshops in:

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* 6. Leader Agreement:
Trainee Leaders Must

1. Attend all 4 days of training in order to be able to deliver workshops.

2. Deliver the workshop only as outlined in the course manual.

3.Commit to delivering two workshops per year for the Central West Self-Management Program.

Workshop leaders are not employees of the Central West Self-Management Program. An honorarium is provided following delivery of a 6 week workshop. Leaders must deliver the workshop only as outlined in the course manual.

I agree to deliver two Self-Management Workshops within 12 months of completing training and two workshops per year thereafter. I will deliver in strict accordance with the course as written in the Leaders Manual, and as taught at leaders training. I will attend all four days of leader training.

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* 7. In order to complete this application, please submit a police Volunteer Record Search (Vulnerable Persons).

Police record check information:
Records Search Unit
7750 Hurontario Street
Brampton, Ontario
L6V 3W6
Records Search Unit – Contact & Automated Information
(905) 453-2121 ext. 4390


Business Hours
Monday through Friday
8:00 a.m. to 6:00 p.m.
10:00 a.m. to 2:00 p.m.
Closed on statutory holidays

Individuals living outside of Peel need to contact their community’s Police Services for a criminal records check.